Chest Pain (cont.)

Benjamin Wedro, MD, FACEP, FAAEM

Dr. Ben Wedro practices emergency medicine at Gundersen Clinic, a regional trauma center in La Crosse, Wisconsin. His background includes undergraduate and medical studies at the University of Alberta, a Family Practice internship at Queen's University in Kingston, Ontario and residency training in Emergency Medicine at the University of Oklahoma Health Sciences Center.

Daniel Lee Kulick, MD, FACC, FSCAI

Dr. Kulick received his undergraduate and medical degrees from the University of Southern California, School of Medicine. He performed his residency in internal medicine at the Harbor-University of California Los Angeles Medical Center and a fellowship in the section of cardiology at the Los Angeles County-University of Southern California Medical Center. He is board certified in Internal Medicine and Cardiology.

Melissa Conrad Stöppler, MD

Melissa Conrad Stöppler, MD, is a U.S. board-certified Anatomic Pathologist with subspecialty training in the fields of Experimental and Molecular Pathology. Dr. Stöppler's educational background includes a BA with Highest Distinction from the University of Virginia and an MD from the University of North Carolina. She completed residency training in Anatomic Pathology at Georgetown University followed by subspecialty fellowship training in molecular diagnostics and experimental pathology.

What is the diagnosis and treatment for chest pain?

Treatment for chest pain depends upon the cause. Many times, situations require that the evaluation, diagnosis, and treatment occur at the same time, but when there is opportunity, the sequence of history, physical examination, testing, diagnosis, and treatment should be followed. A synopsis of common chest pain presentations and treatments follows.

The chest wall

Broken or bruised ribs

Bruised or broken ribs are common injuries. Symptoms of broken or bruised ribs include:

tenderness over the site of injury;

a broken rib may be palpated (the health care professional can feel the rib fracture move when pressed);

the pain tends to be pleuritic (it hurts to take a deep breath and can be associated with shortness of breath); and

because the surrounding muscles go into spasm, there is pain with any movement of the trunk.

The health care professional will want to listen to the chest to make certain that there is no associated lung damage. Sometimes, subcutaneous emphysema can be felt, a sensation of feeling rice krispies when air leaks into the skin. A chest X-ray may be done to look for a pneumothorax (collapsed lung) or pulmonary contusion (a bruised lung). Special X-rays looking for rib fracture are not needed since the presence or absence of a fracture will not alter the treatment plan or recuperation time. Special attention will be given to the upper abdomen since the ribs protect the spleen and liver, to make certain there are no associated injuries.

The major complication of rib injuries is pneumonia. The lungs work like bellows. Normally, when one takes a breath, the ribs swing out and the diaphragm moves down, sucking air into the lungs. Because it hurts to take a deep breath, this mechanism is altered, and the lung underlying the injury may not fully expand because the patient cannot tolerate the pain. The result is stagnant air and lung tissue that does not fully expand, causing a potential breeding ground for lung infection (pneumonia).

Rib injury treatment may include:

Pain control with anti-inflammatory medications like ibuprofen and narcotic pain medications to allow deep breaths to occur.

Application ice to the affected area and periodically deep take breaths. An incentive spirometer may be provided to help visualize the amount of breath to take.

Ribs are no longer wrapped or taped to help with comfort. Wrapping ribs decreases the ability of the lung underneath the injured area to fully expand and increases the risk of developing pneumonia.